Examples from diverse contexts show how challenges to implementing and scaling up comprehensive sexuality education can be overcome to support the sexual and reproductive health and rights of adolescent girls, write Sheena Hadi and Marina Plesons

Tremendous progress has been made in improving the sexual and reproductive health and rights (SRHR) of adolescent girls over the past 26 years, as called for by the Beijing Declaration and Platform for Action.¹ Adolescent girls are now more likely to use contraceptives, and are less likely to experience female genital mutilation, be married as children, or have children themselves.²

However, a number of challenges remain. Girls around the world continue to reach puberty unprepared for the changes that will happen to their bodies.² Twenty three million girls aged 15–19 years in developing regions have an unmet need for contraception.² One in five girls aged 15-19 years has experienced intimate partner violence in the preceding 12 months.²

Comprehensive sexuality education (CSE) is recognised as an important intervention that can help to address many of these challenges.³ CSE equips young people with the knowledge, skills, attitudes, and values to develop respectful social and sexual relationships based on egalitarian gender norms.³ When combined with adolescent-responsive health services, CSE has been shown to have a positive impact on knowledge and attitudes about sexuality; communication skills and self-efficacy; and on risk factors that increase risk of HIV/STI infection and unwanted pregnancy, such as age at first sexual intercourse, and use of condoms and contraception.³

Despite this, countries around the world continue to struggle with many aspects of CSE implementation. Challenges include building and sustaining political and social support for CSE, integrating and scaling up CSE within formal and non-formal education systems while maintaining quality, and linking it with complementary efforts to address the health and rights of adolescent girls.⁴ However, innovative and successful approaches are being used to overcome these challenges in diverse settings, including conservative social contexts. 

In one of the co-author’s experience working to improve SRHR in Pakistan, building support for CSE programming has required extensive engagement and relationship building with government officials, community members, teachers, and parents. Working with communities to understand their priorities and sensitivities related to SRHR has been essential for appropriately framing CSE content and terminology for the sociocultural context. For example, child protection was used as an entry point to discuss and build support for CSE with stakeholders, rather than focusing on premarital sexual activity. Clearly communicating the results of CSE programmes to parents and teachers has also helped to increase transparency and understanding. These strategies cultivated a foundation of trust among key stakeholders, which later enabled the institutionalisation of a “life-skills based education” (LSBE, a term used for CSE in Pakistan) curriculum in the province of Sindh when in 2018 a case of sexual violence against a 7 year old girl resulted in a public outcry for greater protection and violence prevention.⁵

In the Jharkhand State of India, having the right institution take leadership and responsibility for coordinating CSE was critical to its sustainability and scale-up. The State AIDS Control Society struggled with the logistics of managing through the health department what was inherently an adolescent education programme (AEP, a term used for CSE in India), until the national government transferred responsibility to the Department of Education in 2007. Identifying the right home for the AEP contributed to its scale-up throughout the state and its sustainability over 15 years. With technical support from the non-government organisation, the Centre for Catalyzing Change, the AEP has reached over one million students. It has improved adolescents’ knowledge about SRHR as well as their self-efficacy, decision making, and communication skills.⁶ As a result, it has been recognised as a model for adolescent education programmes in other states.⁷

A well designed and well executed multisectoral coordination plan was central to the success of Mozambique’s Programa Geração Biz in overcoming silos between SRHR information and health service provision. The programme sought to improve the SRHR of young people by training peer educators to provide SRH education in community settings and in schools, with support from trained teachers, and by improving the availability and quality of adolescent-responsive health services.⁸ From the outset, a group of government ministries and civil society organisations defined clear roles and responsibilities for those involved, and a sufficiently funded coordination structure was established at national and sub-national levels to direct, sustain, and monitor implementation. This collaboration enabled the programme to forge linkages between the different components, scale them up nationally in 2007, and sustain them over the 14 years since.

Finally, an example from San Antonio, Texas in the United States exemplifies the important role of strategic communications in overcoming backlash to CSE. In 2016, a small but vocal group of individuals used social media, recorded phone messages (robocalls), and community meetings to disseminate incorrect and misleading information about a CSE curriculum being introduced within a local school district. School district staff initiated a strategic and well organised response, which included appointing a central spokesperson to continuously restate the facts about the curriculum, keeping senior administration officials updated on the response, and encouraging community members to publicly endorse the curriculum. The school district used in-person and online Parents Preview sessions to share information on the curriculum and the process that had been used to select, approve, and adopt it. This helped to build support and understanding in the community for the curriculum. As a result, the school district’s decision to adopt the curriculum was neither revisited nor rescinded, a major achievement in a state where 96% of schools taught abstinence only or no CSE at all.⁹

CSE offers an important opportunity to build knowledge and understanding of SRHR and to foster equitable gender norms that improve girls’ agency and opportunities, now and in the future. Its importance was reiterated and underscored by the 2020 Generation Equality Forum’s target to increase the delivery of CSE in and out of schools to reach 50 million more children, adolescents, and young people by 2026.¹⁰ The examples we’ve taken from different settings illustrate that the multitude of implementation challenges facing CSE should not impede or discourage efforts to achieve this ambitious target. Rather, they show that such challenges can be overcome by understanding and pragmatically navigating the local demands, power dynamics, and social and political contexts in which CSE programs operate. 

Sheena Hadi is the executive director of Aahung, Karachi, Pakistan. Twitter @sheenahadi @aahungngo

Marina Plesons is a technical officer at the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland. Twitter @MPlesons @HRPResearch

Competing interests: none declared.

References

1. United Nations. Beijing Declaration and Platform for Action. Beijing: United Nations; 1995. Available at: https://www.un.org/womenwatch/daw/beijing/platform/
2.  Liang M, Simelane S, Fillo G, et al. The state of adolescent sexual and reproductive health. Journal of Adolescent Health 2019; 65: S3-15.
3. UNESCO, WHO, UNAIDS, et al. Revised edition: International technical guidance on sexuality education – an evidence-informed approach. Paris: UNESCO; 2018.
4. UNESCO. Policy paper 39: Facing the facts: the case for comprehensive sexuality education. Paris: UNESCO; 2019. Available at: https://en.unesco.org/gem-report/node/2791 
5. Chandra-Mouli V, Plesons M, Hadi S, et al. Building Support for Adolescent Sexuality and Reproductive Health Education and Responding to Resistance in Conservative Contexts: Cases From Pakistan. Global Health: Science and Practice 2018; 6(1): 128-136. 
6. Centre for Catalyzing Change. Programme brochure: Udaan. New Delhi: Centre for Catalyzing Change; 2019. Available at: https://www.c3india.org/assets/c3india/pdf/udaan.pdf
7. Chandra-Mouli V, Plesons M, Barua A, et al. What Did It Take to Scale Up and Sustain Udaan, a School-Based Adolescent Education Program in Jharkhand, India? American Journal of Sexuality Education 2018; 13(2): 147-169.
8. Chandra-Mouli V, Gibbs S, Badiani R, et al. Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve? Reproductive Health 2015; 12: 12.
9. Wiley D, Plesons M, Chandra-Mouli V, et al. Managing Sex Education Controversy Deep in the Heart of Texas: A Case Study of the North East Independent School District (NEISD). American Journal of Sexuality Education 2019. doi:10.1080/15546128.2019.1675562
10. Generation Equality Forum. Action Coalitions: A Global Acceleration Plan for Gender Equality. New York: UN Women; 2021. Available at: https://forum.generationequality.org/sites/default/files/2021-03/AC_Acceleration%20Plan.Final%20Draft%20%28March%2030%29_EN.pdf